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CHERRY PIP BEZOARS

Posted by: Philip Alex | Posted on: July 15th, 2005 | 0 Comments

INTRODUCTION:

Phytobezoars and unusual causes of luminal intestinal obstruction are well documented in both adult and pediatric patients. Most bezoars occur in patients who are mentally challenged. Luminal obstruction has been associated with carcinoid of the ileum. We report a case where a patient had swallowed approximately fifty cherries with the pips under the mistaken impression that it would cure her diabetes.

CASE REPORT

A 35 year old lady, a known diabetic on treatment was brought to our hospital ketotic, with a blood sugar of 547mg%. She was tachynpoeic, and comatose. She had complained of abdominal pain and her relatives had mentioned that she had eaten quite a few cherries that day. She was intubated, resuscitated, started on an insulin glucose infusion. Her blood sugar levels gradually decreased to 229 over the next 8 hours. She was tender in the abdomen. Abdominal x rays did not reveal any abnormality. She was taken up for a laparotomy twelve hours after her presentation. On laparotomy about fifty cherry pips were found causing luminal obstruction at the terminal ileum from sheer mass effect. They were milked into the colon through the ileocaecal valve, upon which the obstruction was relieved. She made an uneventful recovery. On questioning, she admitted to having eaten these cherries on the assumption that this would cure her diabetes.

DISCUSSION

Intestinal obstruction is a common medical problem and accounts for a large percentage of surgical admissions for acute abdominal pain. Small intestinal ileus is the most common form of intestinal obstruction; it occurs after most abdominal operations and is a common response to acute extra-abdominal medical conditions and intra-abdominal inflammatory conditions. Mechanical small bowel obstruction is somewhat less common; such obstruction is secondary to intra-abdominal adhesions, hernias, or cancer in about 90% of cases. Mechanical colonic obstruction accounts for only 10% to 15% of all cases of mechanical obstruction and most often develops in response to obstructing carcinoma, diverticulitis, or volvulus.

Among secondary causes of small bowel obstruction the most common cause remains postoperative adhesive obstruction. Various other causes have been described and rigorous work up and evaluation have been described. Acute intraluminal occlusions have been less frequent, and the subject of varied case reports. Among them bezoars are the most common, usually in patients with depressive illness and psychiatric illness., Other rare causes of intestinal occlusions have been described, among which are enteroliths occurring with jejunal diverticulae, undigested food, including a green chilly, anasakiasis and small bowel haemangioma. Bezoars have been described with undigested food and vegetable matter serving as nuclei. Bezoars of vegetable matter causing obstruction have been described in the pediatric population, with cherry tomato pips and grape seeds serving as bezoars., Carcinoids of the ileocaecal area have been associated with ten fruit pip bezoars in an adult. We describe probably the first case report of an en masse obstruction caused by fifty cherry fruit pip bezoars without antecedent obstructive cause. The sheer volume of the number of pips probably caused the obstruction. We recommend milking them beyond the ileocecal valve without the necessity for an enterotomy.